Treating Addiction and Relapse

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1.   Biopsychosocial

As a clinical disorder, addictionOpens in new window requires long-term treatment that should and can only be measured in months and years. Is it recommended to individualize the treatment process of addiction. Further, a complete evaluation is required in order to trace any co-existing medical, psychiatric and social problem that require redress together with the addiction treatment. Key to successful treatment of addiction is long-term prevention of relapse by pharmacological and behavioral means.

A biopsychosocial model of addiction entails treating addiction from all three fronts, thus, medicinal, psychological and social. It should be noted that addiction treatments vary depending on the form and level of addiction.

Traditionally, strategies for preventing relapse have involved counseling and/or psychotherapy. However, more recently, pharmacotherapies and technologies combined with cognitive psychotherapies have been adopted and employed in treating addiction and preventing relapse.

2.   Pharmacological Prespective

Some of the effective medications for treating opiate dependence include buprenorphine (commonly known as Suboxone^®), Vivitrol^® (extended-release naltrexone), and methadone.

Each of these three medications has been proven significantly more effective at preventing drug use relapse than a placebo in rigorous, double-blind experimental studies. The types of medication that have been found to be effective when combined with behavioral treatment in preventing relapse (like those stated above) can be classified as agonists, antagonists and anti-craving medications.

These medications work through a variety of mechanisms. For instance, methadone is a full agonist and works by activating the opiate receptor, diminishing cravings for opiates and preventing euphoria if the patient abuses opiates.

On the other hand Vivitrol^® contains extended-release naltrexone, which is a complete mu-receptor antagonist, meaning it completely blocks the mu-receptor. As a result, Vivitrol^® prevents an individual from experiencing euphoria if he or she abuses any opiate, helping to prevent relapse, whilst Buprenorphine is a partial mu-agonist. It prevents the patient from going into withdrawals or experiencing cravings, while preventing euphoria from any opiate used (including too much buprenorphine).

Aside pharmacological interventions, recently, researchers have explored the use of non-invasive brain stimulation techniques to treat addiction.

From a symptomatic approach, it is tempting to think that non-invasive brain stimulation (NIBS) techniques, such as rTMS and transcranial Direct Current Stimulation (tDCS), may be of interest for individuals suffering from IA, as is the case in SUD.

Indeed, the PubMed/Medline database contains more than thirty studies on the use of NIBS techniques to treat substance use disorder, including alcohol, tobacco, cocaine, cannabis, and methamphetamine. In most of these studies, brain stimulation seemed to lead to a significant decrease in craving, both in baseline and cue-induced craving, and may have led to an improvement in decision-making by reducing both impulsivity and risk-taking behavior.

3.   Psychological Perspective

There are a number of behavioral interventions that have been found to effectively treat addictions. These interventions mainly involve behavioral therapy including motivation interviewing, contingency management therapy and the most adopted interventions- cognitive behavioral therapy.

Contingency management provides tangible reinforcers for achieving target behaviors to increase the likelihood of those behaviors reoccurring.

Typically, contingency management interventions identify an appropriate target behavior (e.g., abstinence as verified by a negative urine toxicology test) and provide tangible reinforcers each time the target behavior occurs. The reinforcers are most often monetary-based vouchers exchangeable for retail goods and services or the chance to win prizes of varing magnitudes. If the target behavior does not occur, the reinforcers are removed.

Cognitive behavioral therapyOpens in new window is an individualized, collaborative approach to psychotherapy that emphasizes the importance of thoughts, feelings, and expectancies and also incorporates more traditional behavioral approaches that utilize counter-conditioning and contingency management in addressing the problem of addiction. It combines two very effective kinds of psychotherapy—cognitive therapy and behavioral therapy.

Cognitive behavioral therapy is based on a number of theories including, social learning theory, stress theory and coping theory. It underlines that the learning processes play an important role in the development and continuation of addiction as well as reducing and treating addiction.

Further, this intervention is cognizant of the view that stressors are likely to trigger addictive behavior as a coping strategy to avoid experiencing distress. As such, cognitive behavioral therapy focuses on challenging individuals’ positive expectancies about substance use, enhancing their self-confidence and self-efficacy to resist addictive behavior and tendencies.

Mainly, cognitive behavioral therapy helps clients in two major behavioral ways.

• The first is to help reduce the intensity and frequency of their urges to use or engage in addictive substance or behavior, by undermining their underlying beliefs or cognitions about the substance or behavior.
• The second is to teach the clients specific techniques for controlling or managing their urges to use or engage in addictive substance or behavior.

Cognitive behavioral therapy has been demonstrated to facilitate effectively improvement for a number of mainstream addictions. Reductions in drinking and drug use were seen mostly when clients were motivated to change and possessed at least a low average intelligence level needed to process and relate thought patterns with behavioral reactions. Treatment gains with respect to stimulant use have been well established, with evidence that gains persist and grow over periods of 6 – 12 months.

4.   Social Perspective

In treating addiction, a biopsychosocial perspective highlights the role of the society/community in prevention of relapse for addicted persons. As highlighted earlier, parents, siblings, friends and the community at large play a critical role in safeguarding treatments of addiction and encouraging addicted persons to stay on course of their recovery.

One of the systematic community approaches that has been proposed and found to be effective is the community reinforcement approach therap. Hunt and Azrin developed this intervention and tested it on persons with alcohol dependence.

The community reinforcement approach is based on the theoretical view that individuals use substances or engage in some behavior for their positive, reinforcing effects and that the relative lack of alternative, non-drug and non-addictive reinforcers maintains dependence.

The development of alternative reinforcing activities that are incompatible with drug us is therefore central to the community reinforcement approach. In the community reinforcement approach, the therapist places a great deal of emphasis on changing environmental contingencies in the client’s life. Employment, recreation, and family systems are all addressed to promote a lifestyle that is more reinforcing than substance use and/or additive behavior.

Rather than being entirely office-based, the community reinforcement approach is typically performed, at least in part, in the community. If clients do not attend treatment or do not follow through with an employment or recreational goal, the therapist may go to their homes, take them to job interviews, or help them try a new recreational activity.

Studies have found the community reinforcement approach to be of therapeutic benefit to alcohol-dependent individuals. Further, several reviews and meta-analyses have concluded that the community reinforcement approach is an important, established, and effective treatment for alcohol use disorders.

Conclusion

This literature has presented a biopsychosocial perspective of understanding and treating addiction. It has stressed the role of society and community in treating addiction, underscoring the social nature of addiction. The assumptions, studies and recommendations presented herein are general, thus, covering both substance and behavioral addictions.

This is based on the understanding that there are striking similarities between substance and behavioral addictions at the clinical, neurobiological and neurofunctional level. This understanding suggests therefore that interventions in treating addiction such as neurostimulation techniques, which are effective in treating substance addiction, could also be effective in treating similar symptoms in behavioral addictions.

As we conclude, it is important to stress that treatment of addiction is complex and should require a combination of techniques in order to adequately treat it and prevent relapse, hence a biopsychosocial approach to treating addiction.

Experimental studies have found that the combination of medication and counseling is more effective than counseling alone at preventing relapse. Also, combining pharmacological and behavioral treatment leads to greater rate of retention than for either counseling or 12-step groups. According to the World Health Organization, the most effective treatment for opiate dependence is medication combined with counseling.